Regional variation in knowledge and practice regarding common zoonoses among livestock farmers of selective districts in Nepal

Background The majority of Nepalese people are involved in farming. However, due to limited knowledge of zoonoses and poor preventive practices on the part of livestock farmers, vulnerabilities to zoonotic diseases are very high. The main objective of this study was to assess the regional variation in zoonoses-related knowledge and preventive practices of livestock farmers in different ecological regions of Nepal. Material and methods Descriptive cross-sectional quantitative research design was followed in the study. The total sample size was 380 livestock farmers from randomly selected three ecological regions of Nepal. Systematic sampling techniques were applied for data collection. Data were entered into an excel sheet and then imported into Statistical Package for Social Sciences (SPSS) software. The data were calculated using descriptive statistics. Univariate, and bivariate analyses were performed, and the result of the study was presented in the form of text and tables based on their nature. Results Of the studied six zoonotic diseases, most of the respondents (95.8%) knew about zoonotic bird flu; 90.7% of them, were about rabies; and 54.2% knew about swine flu. However, a few respondents knew about bovine tuberculosis, neurocysticercosis, and brucellosis. Ecologically, the highest number of respondents in Nawalpur had knowledge of rabies (95.3%), and swine flu (61.6%), whereas 98.3% of them had knowledge of avian influenza in Tanahun; and 12.5% of neurocysticercosis in Manang. Regarding zoonoses preventive practices such as regular hand washing with soap water, mask-wearing, gloves, boots, the respondents’ representation of 60.8%, 6.6%, 1.8%, and 1.3% respectively in such practices show that although these are easy and cost-effective, personal protective equipment (PPE), such preventive practices were extremely underperformed. Not only that, only 12% of respondents maintain a standard distance (>15m.) between their house and shed. Similarly, 17% still consumed meat from sick animals, and vaccination of livestock was also found poor coverage (36%) in the study. Conclusions Livestock farmers need to be more knowledgeable about many common zoonotic diseases, and their preventive practices still need improvement, with significant regional variation in the study. This has invited various zoonosis threats for them. Therefore, it is recommended that the interventional programs related to common zoonoses be conducted for livestock farmers to solve the problem.


Background
As an agrarian country, the majority of the people in Nepal are involved in the farming profession. However, due to limited knowledge of zoonotic and poor preventive practices, vulnerabilities to zoonotic diseases are transmitted from livestock. The main objective of this study was to assess the zoonotic risk to livestock farmers based on their existing zoonotic-related knowledge and practices by applying the quantitative research design.

Methods
The total sample size was 380 from randomly selected three ecological zones of Nepal, and systematic sampling techniques were applied for data collection.

Result
Almost all respondents (91.8%) in the study adopted mixed types of livestock farming. Of the six zoonotic diseases, almost all (95.8%) respondents knew about zoonotic bird flu and rabies (90.7%), whereas only average respondents (54.2%) knew about swine flu. However, the very smallest number of respondents had known about bovine tuberculosis, neurocysticercosis, and brucellosis. Zoonoses preventive practices (i.e., handwashing with soap water 60.8%, mask 6.6%, gloves 1.8%, boots 1.3%, worn regularly) as a piece of personal protective equipment (PPE) provide empirical evidence of poor practices in the study. Not only that, 88% of respondents-built sheds/farms within 15 m. of their residents, 17% of households still consumed meat from sick animals, and vaccination of livestock also found poor coverage (36.0%) in the study.

Conclusion
Many common zoonotic diseases are poorly understood and practiced by livestock farmers in Nepal, with significant regional variation. So, to prevent zoonoses, we need to design interventional activities for livestock farmers based on the prevalence status of specific zoonoses in specific areas.   Additional data availability information:

Regional variation in knowledge and practice regarding common zoonoses in livestock farmers of selective districts in Nepal
Kosh Bilash Bagale 1 , Ramesh Adhikari 2 , Devaraj Acharya 3

Abstracts
Background: As an agrarian country, the majority of the people in Nepal are involved in the farming profession. However, due to limited knowledge of zoonotic and poor preventive practices, vulnerabilities to zoonotic diseases are transmitted from livestock.
The main objective of this study was to assess the zoonotic risk to livestock farmers based on their existing zoonotic-related knowledge and practices by applying the quantitative research design.
Methods: The total sample size was 380 from randomly selected three ecological zones of Nepal, and systematic sampling techniques were applied for data collection.
Result: Almost all respondents (91.8%) in the study adopted mixed types of livestock farming. Of the six zoonotic diseases, almost all (95.8%) respondents knew about zoonotic bird flu and rabies (90.7%), whereas only average respondents (54.2%) knew about swine flu. However, the very smallest number of respondents had known about bovine tuberculosis, neurocysticercosis, and brucellosis. Zoonoses preventive practices (i.e., handwashing with soap water 60.8%, mask 6.6%, gloves 1.8%, boots 1.3%, worn regularly) as a piece of personal protective equipment (PPE) provide empirical evidence of poor practices in the study. Not only that, 88% of respondents-built sheds/farms within 15 m. of their residents, 17% of households still consumed meat from sick animals, and vaccination of livestock also found poor coverage (36.0%) in

Introduction
Agriculture is the prime source of the country's economy, which equally contributes to the livelihoods of the farming communities and has a significant impact on the national Gross Domestic Product (GDP). According to an economic survey published by the ministry of finance, it is estimated that in the fiscal years 2020 /021, out of total GDP, 20.2 percent of the contribution is covered by the agriculture sector [1]. In Nepal, approximately 66% of the population is still engaged in agriculture and livestock farming as a profession [2], with the majority of these being mixed types of livestock farming, including poultry and buffalo. Based on ecological diversity, livestock farmers in Nepal adopt different types of livestock in their households.
Farmers in the Mountains keep Yak / Chauri and sheep whereas farmers in the Hills rear cows, sheep, goats, and poultry, and in Terai, buffalo, cows, goats, and poultry are the major domesticated livestock.
Due to globalization, the industrialization and commercialization paradigms are shifting in the field of livestock farming as a commercial profession. However, they are still adopting traditional and vulnerable farming practices with low knowledge of livestock (vertebrate animals) that transmit human illnesses called zoonoses [3]. Not only that, they use fertilizers, pesticides, or antibiotics for their agro-farming and livestock to get higher production, but they are ignoring their hazardous health implications, including antibiotic resistance. Without proper knowledge of safety and technical guidance, they are facing several vulnerabilities, including zoonotic diseases and huge human and economic losses.
According to Taylor and colleagues, animal sources cause more than 60% of infectious diseases in humans [4]. People who work with or near animals (livestock) are thus more vulnerable to zoonotic infections, which can be fatal. But people are ignoring such realities and also neglecting issues in the country. In Nepal, many zoonotic diseases are prevalent in different forms, i.e., sporadic, endemic, epidemic, and so on [5]. When they get a favorable environment, that may change to a pandemic nature. So, to prevent zoonoses, we need to make knowledgeable at least those people who are close to and caretakers of their livestock (i.e., livestock farmers) by several interventional approaches (i.e., education or training). However, due to limited studies in the field of livestock farming, we have no actual ideas about the knowledge, and practices of livestock farmers related to zoonotic diseases and preventive practices. So, this study aims to identify the realities of knowledge and existing preventive practices of livestock farmers in the different ecological zones of Gandaki province in Nepal.

Materials and methods
This study followed a cross-sectional quantitative research design with a descriptive nature. Respondents were selected by systematic random sampling technique from randomly selected three ecological zones namely; Manang, Tanahun, and Nawalpur districts of Gandaki province in Nepal.

Population and sample size
Farmers who were keeping any types of livestock (including poultry and buffalo) and actively involved in livestock care roles were the population of this study.
Based on the national population and housing census 2011, the total number of households (livestock farmers), including in all study districts (municipals), was 2835.
The sample size in the study was estimated using the probability proportional to size (PPS) sampling technique proposed by Solvin [6], and the total sample size, including 10% for non-response rate, was 390.

Data collection tools, techniques, and analysis procedures
This study was a part of the Ph.D. of the first author. After taking the approval letter from GSE-TU, visited the respective municipalities and took the official approval for data collection. Researchers spent almost 74 days including all study districts for data collection, and a total of 380 respondents took the survey interview with face-toface techniques in their households. In the preliminary phase of the data collection procedure, we established a good rapport with the participants and then explained the research objectives. Standardized tools were used for data collection, which was designed after being reviewed and discussed by experts as a Delphi technique and pretested. The questionnaire is divided into four sections: (i) respondents' sociodemographic status; (ii) knowledge about zoonoses; (iii) zoonoses preventive practice; and (iv) perception measuring questionnaire (perception related parts are not included in the article). According to the nature of the data, collected data was analyzed using descriptive statistics, including bivariate analysis.

Ethical consideration
The study proposal was approved by the research committee board of the Graduate School of Education, Tribhuvan University, Nepal. During the data collection, the ethical standard was maintained as per Nepal Health Research Council (NHRC) guidelines [7].
Verbal consent was taken before the interview and was requested to participate voluntarily. All data were kept confidential with anonymity. Moreover, we also followed the ethical guidelines made by the American Psychological Association (APA) [8] throughout the research process.

Results
This study was conducted in the Manang, Tanahun, and Nawalpur districts which are located in Gandaki province and represent all three ecological zone (Mountain, Hill, and Terai) of Nepal. Among the respondents, 32 (8.4%) were from Manang, 176 (46.3%) were from Tanahun, and 172 (45.2%) were covered by Nawalpur district as probability proportional to size (PPS) sampling technique.

Knowledge of common zoonoses based on ecological zone
Rabies: almost respondents (91%, n=380) had heard about zoonotic rabies.
However, higher respondents in Nawalpur (95.3%, n=172) had known about zoonotic rabies than in the other two districts which seem significant association (p=.007) between zoonotic rabies-related knowledge based on the different ecological zone in the study. Manang, Tanahun, and Nawalpur respectively in the study, and all variables related to knowledge found significant association (p<.001) with the ecological zone of the study.
Bird flu: it is a highly known zoonotic disease among the respondents and also highly infectious in avians. However, due to close exposure without any safety people will get bird flu from their poultry which may be dangerous to the victim. If people have information about the way of disease transmission, they will break this chain which helps to protect from infection. In the case of bird flu, results were found satisfactory in the study. Respondents in all study districts had a higher knowledge of bird flu, it is transmitted due to consumed raw poultry products (meat or egg) with regional variation (p<.001). However, symptoms of bird flu in poultry found poor knowledge among the respondents in Manang and Nawalpur to compare the Tanahun. Swine flu: it is a highly contagious zoonotic disease transmitted by an infected pig (swine). People who are close to infected pigs without safety will be vulnerable to swine  So, based on data, respondents had a good knowledge of zoonotic bird flu and rabies whereas swine flu had average knowledge. However, bovine tuberculosis, neurocysticercosis, and brucellosis found the very least knowledge with significant regional variation in the study.

Zoonoses preventive practices based on ecological zone
Healthy practices determine positive health and well-being. Due to the host and reservoir characteristics of animals, livestock farmers who are close exposure to the livestock are facing vulnerabilities related to zoonoses. So, to protect from zoonoses we need to follow safety practices during the take care/close exposure to the livestock.
However, in this study, only more than half (60.8%, n=380) of respondents had regularly washed their hands with soap water after close exposure to livestock. Ecologically, higher respondents (91.9%, n=172) in Nawalpur regularly wash their hands with soap water than in Manang (71.9%, n=32) and Tanahun (28.4%. n=176). Mask-wearing practices during close exposure also found poor practices in the study, where only 25 (6.6%) livestock farmers wear masks regularly but due to the impact of COVID 19 pandemic 42 percent of farmers used masks occasionally. To compare the results in the studied three districts, respondents in Nawalpur found higher regular mask users (12%, p<.001) with significant regional variation (Table 5). shed is more than 15 meters or 50 fits [9]. Based on ecology, almost respondents in Manang (91%, n=32) maintain this standard than in Nawalpur (9%, n=172) and Tanahun (1%, n=176) with significant regional variation (p<.001). practice was found higher in Manang (72%) than in Nawalpur (14%) and Tanahun (10%).
Vaccination practices for their livestock also found poor coverage in the study. Out of the total respondents' farmers, only two-thirds (36%) were vaccinated their livestock. To compare this practice, Nawalpur had the highest coverage (72%) than Manang (9%) and Tanahun (5%). Based on data majority of the farmers ignored vaccination to livestock as pre-exposure prophylaxis in all ecological zones which may induce zoonoses vulnerabilities to the farming communities and all preventative practices found significant regional variation (p<.001) in the study.

Discussion
As an agrarian country, a large number of people in Nepal are involved in the field of agro or livestock farming [2], and farmers are exposed to zoonotic agents in every aspect of their work. Several studies have found that many zoonotic diseases are prevalent in Nepal in various forms (sporadic, endemic, epidemic, and so on) [5]. So, people who have close exposure to livestock or related professions need to be knowledgeable of livestock-related common zoonoses which are prevalent in their territory.
In this study, we found that avian influenza was the mostly known common zoonotic disease among livestock farmers, followed by rabies and swine flu. However, bovine tuberculosis, neurocysticercosis, and brucellosis had the very least knowledge, respectively. All studied zoonotic diseases have endemic potential in Nepal [10] and have a direct impact on the health of livestock and caretaker farmers. Symptoms look similar to many other human illnesses with low case fatalities, farmers may ignore zoonotic diseases like brucellosis, bovine tuberculosis, and neurocysticercosis in the study.
Knowledge compares on studied zoonoses among the livestock farmers in all three ecological zones, higher respondents in Nawalpur knew about zoonotic rabies, swine flu, bovine tuberculosis, and brucellosis. However, brucellosis and bovine tuberculosis had the very least knowledge to Nawalpur. Whereas, respondents in Tanahun found higher knowledge of avian influenza and neurocysticercosis in Manang.
Rabies is a life-threatening zoonotic disease that has endemic potential in many parts of developing countries like Nepal. Due to close contact with livestock without any safety and the burden of stray dogs, almost half of the Nepalese population is at risk and a quarter at moderate risk of rabies [11]. Most respondents in the study heard about zoonotic rabies with regional variation, which was higher than among livestock farmers in Punjab, India [12].
Results compared among the study districts on zoonotic rabies, more respondents in Nawalpur responded with the correct answer on causative agents, mode of transmission, preventive measures, and free ARV services (it is supply based on caseload and institutional demand order) up to the PHC and district level government hospital in the study. However, more respondents in Tanahun responded with the correct answer to the symptoms of rabies. Those results were similar to livestock farmers in Punjab, India [12] and traditional farmers in Jimma, Southwestern Ethiopia, where (82.8%; n = 75) respondents perceived the prognosis of rabies as that of a person who was bitten by a rabid dog and had not gotten ARV would die [13], which was higher knowledge than in this study.
As a health educator data analyzed with a critical perspective, rabies is a fatal disease if the victim does not take an ARV as post-exposure prophylaxis (PEP), however, knowledge of ARV was not satisfactory in this study. Due to poor knowledge of disease fatalities and free ARV services, people may not perceive disease threats and refuse ARV, which contributes to the rabies burden in the Nepalese community and also creates a challenge to achieving rabies eradication by 2030 in Nepal [14].
Similarly, avian influenza is mostly known as a zoonotic disease in all studied Swine flu is a highly contagious disease with a pandemic nature. In 2009, a pandemic outbreak began in Mexico [16]. People who are involved in pig farming or anyone who has close exposure to pigs and related professions is more vulnerable to swine flu. In this study, only more than half of the respondents had heard about swine flu, which indicates vulnerability to zoonotic swine flu in farming communities. To compare the study of three districts, more respondents in Nawalpur had knowledge of swine flu than in Tanahun and Manang. This result was very low compared with the study in Punjab, India, where almost all respondents had heard about swine flu [12]. So, for farmers who are close to swine, this type of knowledge will help to protect against several zoonotic diseases, including swine fever.
Similarly, very few respondents (3.1%) had heard about bovine tuberculosis (BTB), with higher respondents in Nawalpur responding to the correct answer than in the other two districts. However, the percentage of correct responses in all variables was found very low in all study districts. It was poor knowledge of the livestock farmers in Punjab, India [12], smallholder dairy farmers in North Shewa, Ethiopia [16], and community people in Ghana [17].
It is a cattle-related common zoonosis, but most livestock farmers in Nepal have little or no knowledge of bovine tuberculosis, which poses a challenge not only for veterinarians but also for public health and community members. A study conducted in Chitwan, Nepal, found that in 60 TB patients' households, 15 percent of livestock were found to be BTB, and all TB patients were involved in feeding, milking, and other roles of taking care of livestock, and one-fourth of patients' habits of raw milk consumption [18]. Those types of practices are vulnerable to further disease transmission in the community. Another study showed that in households with 50 cattle, after the intradermal cervical tuberculin test, 10 percent of animals were found to have Mycobacterium bovis [19]. However, due to a lack of proper study, we had no data on the proportion of human tuberculosis cases from bovine sources. However, it is believed that most of the extrapulmonary (EP) tuberculosis cases in humans are from bovine sources [20].
Brucellosis is the second most important disease in the world after rabies, and it has been reported as endemic in Nepal [21]. Respondents had the least knowledge about brucellosis, with only 1.6 percent having heard about it, which was very low in comparison to the finding [22] in Tajikistan, where 15.0 percent of respondents had heard about brucellosis, and a similar finding found in Shewa, Ethiopia [23], but none of the respondents had heard of such a disease as brucellosis in South-western Ethiopia [13]. In comparison, 88 percent of farmers in Kars, Turkey, were aware of brucellosis [24], and livestock farmers in Punjab were also aware of the disease [12]. This study also proved that brucellosis-related knowledge in respondents seems associated with the economic and educational status of the countries, which was proved to compare the studies on Punjab, India, Kars, Turkey, Ethiopia, and Nepal.
In the same way, knowledge of neurocysticercosis was low (2.7%) compared to the study in Southwestern Ethiopia, where two-thirds of the traditional farmers (n = 48) knew taeniasis. They also shared that taeniasis is transmitted to humans when raw meat [Taenia saginata (beef tapeworm), Taenia solium (pork tapeworm)] is consumed [13], but more than two-thirds of traditional farmers had a habit of raw meat consumption, and among the raw meat consumers, almost all have been infected by taenia saginata at least once previously. Several patient reports from Asian countries indicate the wide prevalence of taenia solium cysticercosis, and it is the major cause of epilepsy in Indonesia, Vietnam, and Nepal [25]. When compared with the other three districts, respondents in Manang found higher correct answers in all knowledge measuring questionnaires (3.1-12.5%) than in other districts.
Human behaviors and practices are influenced by their existing knowledge, socio-cultural values, or perceptions in a particular context. In the context of Nepal, most livestock farmers follow the traditional practices, adopting mixed types of livestock farming and exposing themselves to safety. However, due to host and reservoir characteristics of several lethal pathogens, caretaker farmers are facing susceptibilities to zoonotic diseases in their keeping livestock.
As a care taker, livestock farmers need to take some precautions to prevent zoonotic diseases. Hand washing, mask use, gloves, and boots are some of the low-cost and effective practices for preventing several highly contagious zoonotic diseases.
However, only more than half (60.8%) of respondents in this study wash their hands with soap and water on a regular basis after close exposure to their livestock, and similar practices were found in all ecological zones in the study. In contrast, in a study in Chitwan, Gorkha, and Tanahun districts, a higher number (94.0%) of smallholder farmers wash their hands with soap water after handling livestock [26], and in a study in the suburban areas of Bangladesh, where (100.0%) of smallholder livestock farmers wash their hands with soap water after interaction with animals [27]. Those results found an association with several motivational and interventional activities by the research project to compare with the current study.
Mask wearing during close exposure to livestock was also found to be poor practice in the study, where only seven percent of respondents used masks regularly.
However, due to the impact of the threat perception of the COVID-19 pandemic, nearly half were used occasionally in the study. Ecologically, the very worst scenario was found in Tanahun (1%) than in Manang (6%) and Nawalpur (12%), and this finding was found similar to farmers in Kars, Turkey [24], where equal respondents like this study (6.6%) used masks regularly, but 84% of farmers considered it necessary.
Gloves worn regularly during close exposure to their livestock were also found to be poor practices (1.8%) in the study. More than two-thirds of respondents never used gloves, and nearly one-third used gloves occasionally. Ecologically, respondents  [29]. But in another study in Bangladesh, nearly half (43.0%) of the farms were attached to their houses [27].
From the public health point of view, the standard distance between a house and a shed is more than 15 meters or 50 feet [9], which is maintained only by a few (12%) respondents in the study.
In comparison to the other districts studied, nearly all respondents in Manang found it easier to keep the distance between home and shed than in Tanahun and Nawalpur, and there was a significant association (p< .001) with these practices. One aspect of distance maintenance in Dharapani, Manang was that residents restricted livestock entry into the residential area.
Several zoonotic diseases like rabies, brucellosis, avian influenza, swine flu, neurocysticercosis, bovine tuberculosis, etc. are considered to be potential zoonotic diseases in Nepal. Along with these diseases, several other zoonotic diseases exist that will be transmitted to humans mainly through direct contact during taking care or other close exposure without PPE to the infected animal. The majority of respondents in the study (88.0%) disposed of dead animals in the borehole. The remaining few were thrown into the nearest river, which found similar practices on smallholder farmers in Nepal [26] where 18 percent of them disposed of animal waste (like; placenta) on the ground, in water, or on a tree as a customary practice was found vulnerable to zoonotic transmission. In Tanahun, Nawalpur, and Manang, respectively, 100, 89, and 19 percent of respondents dispose of dead animals in boreholes. Those practices show a significant association with an ecological zone in the study (p = .001).
There were several influencing factors for close exposure to children and livestock. Either to minimize the parent's workload or as a normal refreshment activity, the children of the respondents were closed to livestock in the study. More than twothirds of respondents in the study disclosed that their children had had close exposure to livestock. Ecologically, Nawalpur had more respondents who avoided those practices (55.2%) than Tanahun (15.3%) and Manang (12.5%), with significant ecological variation (p< .001). Not only in Nepal, but similar practices are also recorded in other parts of the globe, mainly in poor or developing countries. Similar results (70.0%) were revealed in suburban areas of Bangladesh, where children of respondent farmers had close exposure to their animals [27]. This may impact the education and economic status of the livestock farmers, who are found similarly in Bangladesh and Nepal.
Not only children, but more than two-thirds (65%) of the respondents' farmers stated that pregnant women were also close to their livestock as caregivers. These practices were found higher in Manang than in other districts and showed a significant association based on the ecological zone in the study (p<.001). Due to poor immunity, those types of exposure create a higher vulnerability to the health of the mother, fetus, or younger children from zoonotic diseases.
The consumption practices of sick or recently dead animals are influenced by several socioeconomic statuses. However, some of the respondents in this study (17%) still consume those practicing in their communities. These practices were found to be more prevalent in Manang (72%), than in Tanahun (14%), and Nawalpur (9.7%), with a significant association with the study's ecological zone (p< .001). In contrast, a study in Kars, Turkey, revealed good knowledge related to sick and dead animals, where four out of five respondents knew that they should be buried deep and practiced by one-fifth [24].
Most communicable diseases (including zoonoses in livestock) will be controlled by a cost-effective single-dose vaccination. However, due to several obstacles, farmers are facing many losses in the field of livestock farming. In this study, vaccination practices were also found to have poor coverage among the respondents.
Only two-thirds of farmers vaccinated their livestock as pre-exposure prophylaxis.
Vaccination practices for their livestock were found higher (78.26%) in suburban areas of Bangladesh [27] than in this study. To compare the practices, Nawalpur had the highest coverage (72%) than Manang (9%) and Tanahun (5%) and showed a significant association with the study's ecological zone (p< .001). The majority of the respondents in the study ignored vaccination as pre-exposure prophylaxis in all ecological zones, which may be responsible for zoonotic outbreaks anytime and anywhere.

Conclusion
As an agrarian country, majority of the people in Nepal are involved in the farming profession, and they are exposed to zoonotic agents in every aspect of their work. So, to prevent zoonoses, they must have the knowledge and skills to follow preventive practices. However, the majority of them had no good idea about many of the studied zoonotic diseases that are endemic in their territory, and we found a significant regional variation in knowledge and zoonotic disease preventive practices in the study. If we make the livestock farming profession safer from the perspective of zoonoses through several interventional activities, it is not only a contribution to healthy livestock and healthy farmers but also equally contributes to poverty eradication and support for national GDP.